Health Care for Women International
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Gender, Sexual Health Seeking Behavior, and HIV/AIDS Among Tarok Women in North-Central Nigeria Titilayo Cordelia Orisaremi To cite this article: Titilayo Cordelia Orisaremi (2014): Gender, Sexual Health Seeking Behavior, and HIV/AIDS Among Tarok Women in North-Central Nigeria, Health Care for Women International, DOI: 10.1080/07399332.2014.971953 To link to this article: http://dx.doi.org/10.1080/07399332.2014.971953
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Health Care for Women International, 00:1–18, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2014.971953
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Gender, Sexual Health Seeking Behavior, and HIV/AIDS Among Tarok Women in North-Central Nigeria TITILAYO CORDELIA ORISAREMI Department of Sociology, Bingham University, Nasarawa State, Nigeria
In this study, which was part of a larger project I undertook in Northcentral Nigeria, I explored the differences in the sexual health seeking behavior of Tarok women and men and how these differences affect the spread of HIV. With the help of three research assistants, I conducted 16 in-depth interviews and 24 focus group discussions in four Tarok communities in North-central Nigeria. I found certain negative effects of gender inequality on women’s sexual health seeking behavior in particular, a situation that has adverse implications for HIV acquisition and transmission. I therefore concluded that addressing the challenges of gender inequality is imperative for a sustained fight against HIV and AIDS in Nigeria.
BACKGROUND Nigeria, the most populous country in Africa, reportedly bears the second highest burden of the human immune deficiency virus (HIV) in the world after South Africa because of its large population size (National Population Commission [NPC] & ICF Macro, 2009). The United Nations Joint Programme on HIV/AIDS (UNAIDS,]2010) estimated that 2.9 million people live with HIV in Nigeria and that women account for 56% of all adults aged 15 years and above who lived with the virus in 2009 in Nigeria. Each year, around 57 000 babies are reportedly born with HIV, most of whom became infected from their mothers, and the estimate of children living with HIV in Nigeria alone reportedly increased from 220,000 in 2007 to 360,000 in 2009 (UNAIDS, 2010). Not only are sexually transmitted infections (STIs) closely related to Received 1 November 2013; accepted 25 September 2014. Address correspondence to Titilayo Cordelia Orisaremi, Department of Sociology, Bingham University, PMB 005, New Karu, Nasarawa State, Nigeria. E-mail: [email protected] 1
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HIV, they are quite common in developing countries and constitute critical issues in public health (Ogunsola, 2006). Nigeria, a country in the West African subcontinent that lies between 0 4 1’ and 1309’ north latitude and between 202’ and 1403’ east longitude, is bordered in the east by the Republic of Cameroun; Republic of Chad in the northeast; north and west by the Republics of Niger and Benin, respectively; and on the south by the Gulf of Guinea. With a total land area of about 923,768 square kilometers, Nigeria’s 2006 population figure was put at 140,003,542 (Federal Republic of Nigeria, 2007) and 167,000,000 in 2011. Approximately two-third of these people live in rural areas. Nigeria is occupied by sundry ethnic groups with distinct traditions, customs, and languages. The Hausa, Fulani, Igbo, and Yoruba are the largest and politically dominant ethnic groups. The country is organized into 36 states and a Federal Capital Territory that make up the Federal Republic of Nigeria. These are subdivided into 774 Local Government Areas. The 36 states are further grouped into six geopolitical zones, namely, North-east, North-west, North-central, South-east, South-west, and South-south. The Tarok ethnic group is found in the Plateau State located in the North Central geopolitical zone that is characterized by a massive concentration of small ethnic groups of autonomous political systems. Since 1991 HIV prevalence in Nigeria has been primarily tracked through the sentinel surveillance of pregnant women (15–49 years) antenatal clinic (ANC) attendees (NPC & ICF Macro, 2009). There is a wide variation of prevalence of HIV epidemic in Nigeria across the six geopolitical zones. The North-central zone had the highest HIV prevalence among ANC attendees with 7.5% compared with 2.1% in the North-western zone (Federal Ministry of Health, 2010). HIV in Nigeria is generally higher among women than men. For instance, an analysis of the 2007 National HIV/AIDS Reproductive Health Survey (National Agency for the Control of AIDS [NACA], 2013) by sex and gender showed 1.9% prevalence for young men aged 20–24, while young women of same age recorded 4.5%. Also, the prevalence reported for young women aged 20–24 was 4.6% compared with 3% among mostly unmarried young women of 15–19 years (NACA, 2013). Besides, the same report shows that the Plateau State has one of the highest HIV prevalence rates in the North-central zone (7.7%). The major determinants of sexual health in Nigeria are sociocultural, economic, and psychological factors among others. STIs, which include bacterial, viral, fungal, and all contagious infections transmitted mainly through “sexual contact with mucous membranes and/or skin surfaces” (Ogunsola, 2006), are quite common in various communities in Nigeria, and an active untreated STI facilitates the sexual transmission and acquisition of HIV. Hence, some previous studies reveal a relationship between untreated STIs and HIV in Nigeria as in other parts of the world burdened with the HIV and AIDS epidemic (Dixon, 2004; Ogunsola, 2006).
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Sociocultural factors are critical in the prevention and treatment of STIs and, by extension, in HIV prevention and management. In addition to influencing the spread of STIs, they induce the manner in which men and women access available modern medical services. Nigeria, which is in the main, heterosexual, and the subsisting patriarchal social structure that is pervasive in societies across Nigeria and indeed Africa, translates gender differences to discrimination and inequality to the detriment of women. Female subordination does not necessarily mean that every man is better off than every woman. Nevertheless, it remains true that more men have greater access to scarce resources and decision making than women. Gender inequality is significant because it inhibits women from being able to determine the nature of their sexual relationships, partnership, and behavior. This negatively affects the sexual health and general well-being of women in particular and limits their ability to make informed choices in relation to practices that directly affect their sexual well-being, including the right to seek health care.
RELEVANT LITERATURE AND THEORETICAL PERSPECTIVE Ezumah (2003) explored the perceptions, practices, and norms underlying sexuality gender relations that constrain STI and HIV prevention and control among the Igbo, and the following factors were found to encourage men and women in engaging in sexual networking: (a) persistence of group norms that attribute passivity to women and control in sexual matters to men; (b) marriage that further disempowers women in sexual matters; (c) fear of repercussion which prevents women from negotiating safe sex practices with their male partners; and (d) persistence of harmful cultural practices that predispose women in particular to STIs and HIV. Dixon (2004) asserted that chronic untreated sexually transmitted diseases (STDs) “are far more common in poorer nations where there are fewer health facilities” and “One of the reasons HIV is spreading so fast in Mumbai in India is that around half of all adults in that vast city are carrying an active untreated STD” (p. 51). The presence of health facilities, however, does not predictably translate to equal access by men and women. Unequal gender relations and other sociocultural factors render untreated STIs a challenge especially for women. Hence, Aniekwu (2002) maintained that sociocultural, legal, and economic factors contribute to women’s susceptibility to HIV and AIDS in Nigeria. Also, Makinwa-Adebusoye (2006) studied the sexual and reproductive health of married adolescents in Northern Nigeria and demonstrated that although sexual activity among female adolescents mainly occurs within the context of marriage, young brides are exposed to STIs because they are married to men who are much older and with whom they have very little capacity to discuss life-threatening infections like HIV/AIDS or to seek health care without their husbands’ consent.
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An investigation into how gender issues influence the outcome of an HIV/AIDS intervention program in Zimbabwe revealed that gender power relations and gender roles in families hinder free flow of communication between female and male spouses and increase the vulnerability of married women unlike their unmarried counterparts (Matshalaga, 1999). Also, the social practice of double standards was identified as an important factor in the transmission of HIV in southeastern Nigeria (Smith, 2007). From a Christian perspective, a study (Togarasei, 2011) reviewed certain African cultural and religious beliefs and practices and argued that they have the potential both for increasing and reducing the spread of HIV and AIDS. Interestingly, virtually all the factors identified were gender related. Furthermore, a consultative study with Christian religious leaders in east and southern Africa on multiple concurrent partnerships reveal how women are blamed for men’s extramarital affairs and how their physiology and a male centered culture makes them suffer far-reaching implications of untreated STIs more than their male spouses (Njoroge & Wanjiru, 2010). Some of the implications mentioned in the study were reproductive tract infections, HIV, cervical cancer, infertility, and sterility. Besides, in a medical study on the role of STIs in HIV transmission in Nigeria, Ogunsola (2006) cited data from other sources that support the existence of a close relationship between STIs and HIV demonstrating that the mere presence of an untreated STI increases the risk of acquiring and transmitting HIV 10 times, while proper management of STIs has the potential to reduce the incidence of HIV infection by 40% in the general population. These studies point to the role of gender inequality in the spread of STIs and HIV within regular relationships, as well as women’s poor access to decision making in STI/HIV prevention. Persson and Richards (2008), however, cautioned against a mere generalized description of gender and power in the vulnerability of women to HIV. They explored the interactions between gendered meanings that surround different serostatuses of heterosexual couples. Specifically, they analyzed the gendered interchange between HIV-negative women and their HIV-positive male partners and the complex ways through which the former negotiate their sexual lives with their HIV-positive male partners in Australia and how gendered meanings attached to women’s negative status help the HIV-positive men to regain their masculinity through what the authors described as “proxy negativity.” Nonetheless, my examination of sexual health seeking behavior and STIs here includes certain anatomical properties of the woman. I shall therefore situate this study within a revised version of Robert Connell’s (1987) theory of gender and power. The theory of gender and power which was developed by Connell (1987) identified three major social structures that characterize the relationship between men and women: (a) the sexual division of labor; (b) the sexual division of power; and (c) the structure of cathexis. These structures operate at both the societal and institutional levels. The presence of imbalance of
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control within relationships, and other discriminatory and institutional practices that are maintained by social mechanisms that hinder women’s control of resources and produce gender-based inequities in expectations of women’s role in society, adversely affect women’s health. Wingood and DiClemente (2000) elaborated upon the theory and developed a public health model out of it. They specifically used it to examine not only the exposures and social and behavioral risk factors but also the biological properties that predispose women to HIV. They identified three domains of interest: public health, social behavioral sciences, and medicine, and they explained that each of these domains corresponds to a level of causation that defines the properties that can both increase women’s risk of disease and prescribe particular strategies for decreasing women’s health risk. For instance, for effective intervention at the public health level, it is important to aim at modifying existing social norms, influencing cultural norms, and reducing barriers to health care. At the social/behavioral level, focus should be on modifying intrapersonal and interpersonal factors through individual and group counselling aimed at altering beliefs, attitudes, and so on. At the biomedical level, the target should be at altering the behavior of individuals by addressing their undesirable health conditions through changing their biochemistry. I judged this model adequate for the current study primarily for the following reasons: (a) it recognizes the interplay between existing social mechanisms present in social institutions (including family relationships and medicine) and how they act to expose women to several socioeconomic, behavioral, personal and medical risk factors and diseases; (b) it provides a holistic approach to explaining how unequal gender power influences women’s health, especially sexual health; and (c) it explains the link between perceptions of symptoms and health-seeking behavior. From the foregoing, concerns of sexual health include medical and nonmedical conditions, and the latter provides the much-needed enabling environment for it to thrive. Preventive campaigns are insufficient especially in this era where HIV/AIDs and other STIs have increasingly become development issues. The main objective of this article, therefore, is to go beyond the provision of modern sexual health information and services to explore in-depth and document how gender inequality influences sexual health seeking behavior and the implication of this for the sexual acquisition and transmission of HIV among the Tarok. The Tarok ethnic group is found in the Plateau State located in the north-central geopolitical zone of Nigeria. The two principal religions in Tarok land are traditional religion and Christianity. The latter, however, has assumed dominance in Tarok land in recent times. In the early twentieth century, Christian missionaries of the Sudan United Mission (SUM) arrived in Tarok land (Shagaya, 2005; Yarnap, 1985). These missionaries brought formal education and medical services, as well as new values such as
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one-man one-wife. The Tarok people embraced Western education and many, upon completion, sought paid employment in the urban centers. Contact with Western lifestyle, the introduction of a cash economy, and so on led to an increase in monogamy especially among Christians. In spite of the spread and the rapid growth of Christianity in Tarok land, traditional beliefs and custom abound. Prevailing gender-based social and cultural beliefs and practices that are traits of resilient patriarchal structures influence virtually every aspect of the sexual life of the Tarok. These include the definition of sexuality, the nature of sexual relations and partnerships for men and women, the nature and types of marriage (Orisaremi & Alubo, 2012), and gender differences in access to decision in relation to the use of available modern health care services. These gender-based differences often translate to gender inequality and provide the context within which sexual norms and behavior exist. As with most ethnic groups in Nigeria, marriage was considered a very important social duty, and procreation was the primary reason for this. Male children were preferred. Men were encouraged in traditional times to marry many women and have large families to cultivate large farmlands. This was generally perceived as a status symbol. Fertility was attributed to women, while virility was characteristic of men. Consequently, stigma and other social burdens associated with childlessness were largely borne by women. Where a married man was found to be sterile, it was possible to secretly arrange for his female spouse to bear children through his agnatic brother, so as to ensure continuity of his patrilineage. On the contrary, a childless wife hardly had a place in her matrimonial home. The most common option available to her was to encourage her husband to marry other women capable of bearing children to obviate her shame. Thus, as in many other societies in Nigeria, infertility was a major reason for women’s acceptance of cowives (Orisaremi, 2010). The Tarok practice strict lineage exogamy. Until the introduction of Christianity, the residential pattern was predominantly patrilocal, whereby the man and each uterine family had a separate hut. This residential pattern implied that authority, control, and inheritance were vested in the male head of the family, and it also facilitated the practice of polygyny. Sociocultural beliefs and norms rooted in patriarchal structures, as well as unequal gender relations, play a critical role in the sexual health seeking behavior of married couples in Tarok communities.
METHODS This study was part of a larger research titled Gender Relations and the Reproductive Health of Tarok Women, which was aimed at exploring how
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unequal gender relations influence the reproductive processes and the reproductive health of Tarok women in Nigeria. Fieldwork was conducted in four Tarok communities in the Langtang North Local Government Area of the Plateau State, namely, Langtang, Gazum, Reak, and Pilgani in April–May 2008. Gazum and Reak are rural, while Langtang and Pilgani are urban areas. These localities were selected because traditional sociocultural practices that are significant to this study are usually better preserved at the grassroots, while changes that have taken place over time are better depicted in urban areas. I used in-depth interviews (IDIs) and focus group discussions (FGDs) for data gathering. Participants in IDIs in each community comprised a community leader, a religious and a woman leader, as well as a senior modern health service provider from a public or private health facility who had worked in the community for not less than 3 years and was conversant with the sociocultural practices of the Tarok. The focus groups consisted of female and male community members with a good knowledge of the mores, social norms, workings, and practices of the community in relation to the issues of interest. These were purposively selected to reflect the social differences in the communities in terms of age, gender, religion, educational and marital status, etc., and separate focus groups were constituted to reflect these differences and to ensure the homogeneity of each group. A structured questionnaire with 10 simple questions on their sociodemographic background such as age, gender, religion, marital status, highest level of education attained, income earning activities, and so on, was administered to each of the potential participants prior to the constitution of the focus groups. This was to enable an initial contact and to ensure homogeneity in the constitution of the groups for enhanced interaction. The purpose of the research was explained to the selected participants, and informed consent was verbally obtained from each of them prior to the IDI and FGD sessions. Four IDIs and six FGDs (three each for men and women) were conducted in each community. All eligible respondents for the IDI sessions were interviewed. Each IDI lasted about an hour and FGD an hour and a quarter on average. All research issues were canvassed in each IDI and FGD session. This article simply presents the subsection on STIs and health-seeking behavior. The minimum age for the IDI participants was 38 years and 15 years for FGD participants. On the whole, 41.5% of all participants were 50 years and above, while those below 50 years made up 58.5%. Participants of the FGD between 15 and 24 years accounted for 18.6%, and the 25–34 age category constituted 28.5%. Tables 1 and 2 present the background characteristics and distribution of the 16 IDIs and the 24 FGDs. I used loosely structured IDI and FGD guides as the major instruments for data gathering. Flexibility characterized the ordering of the questions so as to circumvent an atmosphere of formality, given the sensitivity of the
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Characteristic District Langtang Pilgani Gazum Bwarat Sex Female Male Age 38–49 years 50–59 years 60–69 years 70 and above Religion Christian Traditionalist Marital status Single Married Widowed Education No formal education Primary Secondary Tertiary Position in community Women leader Traditional leader Religious leader Senior modern health service provider Income earning activity Full-time farming Petty trading and farming Paid employment and farming Paid employment, farming and trading Pensioner in part-time farming Community service and part-time farming Community service only
Number (total N = 16) 04 04 04 04 06 10 05 02 06 03 14 02 01 14 01 03 04 01 08 04 04 04 04 03 02 03 01 02 04 01
Source: Fieldwork, April–May, 2008.
issues associated with sexuality. All IDIs and FGDs were conducted in Tarok, Hausa, and English languages and auto-recorded. All three research assistants and I were involved in the data gathering, transcription, and translation into the English language. This was done within 24 hours of each IDI and FGD, with supplementary information from the notes taken so as to allow for a quick clarification of any confusion or uncertainties and minimize memory loss. To ensure an authentic descriptive account of results, I sorted findings question by question, issue by issue, group by group, and community by community making notes of major opinions, feelings, and attitudes of the groups and participants in order
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Gender, Sexual Health Seeking Behavior, and HIV/AIDS TABLE 2 Social Background Characteristics of Focus Groups Number (total N = 24)
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Characteristic District Langtang Pilgani Gazum Bwarat Sex Female Male Age 15–24 years 25–34 years 35–49 years 50–59 years 60–69 years 70+ Religion Christian Traditionalist Marital status Single Married Widowed Education No formal education Primary certified Attempted secondary Attempted tertiary Income earning activity Full-time farming Petty trading only Petty trading and farming Paid employment and farming Paid employment, farming and trading Pensioner in full-time farming None (schooling)
06 06 06 06 13 11 05 05 05 04 03 02 22 02 02 19 03 05 09 06 04 04 02 04 06 03 03 02
Source: Fieldwork, April–May, 2008.
to have an overview of findings. Thereafter, I organized and presented the relevant aspects of the content of the IDIs and FGDs in line with the major themes that emerged in relation to gender, sexual health seeking behavior and HIV/AIDS in this article using verbatim quotations to illustrate responses where necessary.
RESULTS Gender Differences in Sexual Health Seeking Behavior The majority of the male and female participants held that men find it easier to seek health care for STIs because (a) their anatomy makes it easier to recognize the symptoms; (b) they are more “courageous” to
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talk about it; and (c) more men have the financial resources to pay for treatment:
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The men find it easier to go for treatment because they are often not as shy as the women. . . . Men are courageous; they do not hide their feelings. But the woman feels shy and may be afraid of how to go and tell them in the clinic, while the man will courageously go and face them. (FGD, 35–49, female, no formal education, rural district) Once a man feels the infection in his body, he starts seeking treatment even before the woman starts feeling any pains. . . . That is how God made the man. . . . He knows it is very important to seek treatment for the disease, so he goes and pays for it. (FGD, 25–34, male, secondary, urban district)
This contrasts with the situation of many women who may have to ask for money from their male spouses in order to seek treatment, and who are often too shy to talk about sex organs because of the nature of their socialization: Women cannot go on their own for medication because they do not like talking about it until it becomes really bad. . . . They also find it hard to ask their husbands for money to go to the clinic for such a disease. . . . At most they try traditional herbal treatment like ikun Tarok (a traditional herbal mix). (FGD, 50–59, female, no formal education, urban district) Very few women go easily. Others would go but would not mention what the true problem is. They may therefore be given the wrong treatment. (FGD, 60–69, female, primary education, rural district)
An urban-based middle-aged educated female participant, however, held an alternative view that either of the sexes who needs medical care for STIs goes freely to any health facility without any hindrance: It does not matter. . . . Man or woman can go to the hospital in search of sexual health care.
Interactions with all four senior service providers reveal that STIs are quite common and that while most sufferers tend to seek care from traditional medical practitioners, more men than women access treatment whether from charlatans or qualified service providers. Additionally, participants mentioned that although very few women seek health care for STIs, women who attend ANCs and present any form of complaints of urinary tract infection or lower abdominal pain are usually advised to run STI tests in health centers, and they often test positive. According to the service providers, many women are often not aware that they have STIs, while others who suspect
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they are infected are very shy to discuss it. Many female clients who present with STIs, therefore, tend to complain about lower abdominal pains, which they usually relate to pregnancy:
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The women often come with lower abdominal pains thinking it is pregnancy . . . without knowing it is STI until we find out. (IDI, 52, male, tertiary education, urban district) The women usually have pelvic inflammatory diseases (PIDs). They may complain of itching and lower abdominal pain, so after [the] test, you treat her accordingly. . . . Some may tell you they have painful menstruation, colored and concentrated urine; some will say they are itching . . . they have rash and things like that. Many a times they associate their complaint of lower abdominal pain with pregnancy, and most of those who come with such complaints are pregnant women. (IDI, 47, female, tertiary education, urban district)
Men generally recognize the symptoms faster, and they tend to seek treatment before the women by first patronizing patent medicine stores and herbalists who are mostly men before seeking care in health facilities if the ailment persists. Asked the kind of traditional treatment given for STIs, the vast majority of the participants, young and old, male and female, specifically mentioned the use of traditional herbal treatment (ikun Tarok) and an herbal mix prepared primarily from the roots or leaves of a particular herb called kwakwali and ja-kanwa (red potash): For gonorrhea, there are certain roots used. For instance, roots of kwakwali plant that they mix with some other things. They boil and give it to the patient. The same treatment is used for men and women traditionally. (FGD, 30–39, male, secondary education, urban district) To treat nping gbang-gbang (“smelly urine,” used to refer to gonorrhea), there is a type of leaf called kwakwali that is squeezed and mixed with ja-kanwa, and it is left for about 30 minutes before it is given to the patient to drink. (FGD, 70+, female, no formal education, rural district)
A minority of the participants were of the opinion that in these modern times, however, some of those infected men or women resort to modern health facilities for the treatment of gonorrhea: Gonorrhea was treated with ikun Tarok (Tarok native herbal medicine), but these days it is taken care of in the hospital. (FGD, 60–69, male, primary education, urban district)
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The service providers mentioned that most of the men who visit health centers for STIs often go directly to the men in the laboratory to demand a test instead of consulting the female nurses:
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When male clients come, most of them go straight to the lab man and complain to him. . . . He quietly runs the test, and, if positive, the lab man would now hand over the result to the right personnel for treatment. (IDI, 47, female, tertiary education, urban district)
The service providers equally mentioned that they normally would ask their clients to come with their sex partners. Asked how willing these partners are in accompanying the former for treatment, they said that while most people would agree to accompany their spouses to the clinic for treatment if invited, it is almost impossible to get unmarried sex partners to present together because of the illicit nature of their sexual relationship or cowives in polygynous marriages except where the husband was the first to be diagnosed. Two of the service providers equally mentioned that in some cases the men would ask to be given drugs for their female partners to avoid bringing them to the health centers where most service providers are women. On the other hand, it was reported that the women would rather look for some diplomatic ways of informing their male spouse of the request of the service providers to have a chat with them or pretend not to know why an invitation is extended to their husbands by the service providers.
Perception of How Common HIV Is in the Community and of its Sources of Transmission It is important to note that HIV does not exist in the local dialect. Instead, it is perceived as a synonym for AIDS, and AIDS is referred to in the Tarok language as nanne or fungshat ku zing (nanne or fungshat ku zing literally means “eight” or “seven-plus-one.” It is derived from the similarity in the sound of the words “AIDS” and “eight”). A majority of all categories of participants mentioned that nanne is common in all the communities especially among youth and women. Very few mentioned that it affects both sexes equally. These opinions are illustrated below: In those days there was gonorrhea, which they called tonzere, but now AIDS is more common especially among the youth and young women. (FGD, 50–59, female, secondary education, rural district) There is a lot of cases of AIDS here among both men and women. (IDI, 52, male, tertiary education, urban district)
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There were indications that the very few participants who expressed the view that AIDS is more common among men, based their opinion on the results of medical tests organized by voluntary organizations in which most of the community members tested were men:
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AIDS is more nowadays. . . . There are persons with HIV/AIDS in this community. Some missionaries came to screen people recently, and they found many persons, especially young men, with AIDS. (IDI, 66, male, primary education, urban district)
Asked if the tests were made available to both men and women, the following was the response from one of the participants: Kai! Who will allow his wife to go for such a test in public? It was mainly for men. (IDI, 66, male, primary education, urban district)
An elderly woman explained how widespread AIDS is: These days sexually transmitted infections are found everywhere kaman karshi (like feces ). . . . Our children are dying regularly. . . . No group is exempted. . . . Even the funeral we are just returning from was that of an AIDS sufferer. . . . We simply find our children drying up until they get to the size of this stick (showing her walking stick) and then they die. (FGD, 70+, female, no formal education, rural district)
The dominant opinions can be summarized thus: (a) HIV/AIDS is more recent than tonzere or gonorrhea; (b) gonorrhea and AIDS are more common in all communities; and (c) HIV/AIDS is more common among young persons and women. Some of the sources of transmission of gonorrhea and AIDS identified by participants follow: indiscriminate sexual activities especially among young persons; sexual indiscipline (particularly among men) and monogamy; as well as indecent dressing among young girls. While the young men blamed the girls, young women equally felt that young men were culpable. Also the practice of widow inheritance (ntem akup) that is still relatively common even among Christian men was equally mentioned by a service provider in an urban district as a possible source of transmission of HIV: One thing that worries me most is this issue of wife inheritance. . . . A husband dies, you don’t know what killed him, you go and inherit the wife, and before you know it, the whole family is infected with HIV. There are many cases of HIV, AIDS, and other STIs here and it cuts across all ages and all sexes whether man or woman.
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Remarkably, the majority of elderly male participants expressed the view that tonzere/gonorrhea and HIV/AIDS are not indigenous but foreign infections brought in by young people who travelled out of Tarok land to places where they indulged in licentious behavior. This is illustrated in the following statements:
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Tonzere was a disease brought by those who travelled to Lafia and places like that. (FGD, 70+, male, no formal education, rural district) Gonorrhea was brought back by the men who went for First and Second World War. They brought it from outside the country and it is spread through sex. (IDI, 78, male, primary education, rural district) We did not know anything called AIDS in those days. It is only now that when people travel they come back with it. Even those of us here know that it is not indigenous but imported into Tarok land. (FGD, 60–69, male, primary education, urban district)
This belief largely expressed by elderly men, who curiously are the custodians of culture including moral values, is clearly connected to the moral issues involved in the predominant mode of transmission of HIV infection, which the majority of the participants identified as sex. The belief indicates denial.
DISCUSSION Discussion of STIs among all categories of participants was generally limited to gonorrhea and AIDS. This is clearly related to the fact that among the Tarok, gonorrhea is often used in the everyday parlance of nonmedical persons in general reference to STIs. Accordingly, participants tended to refer to all types of curable STIs as gonorrhea, while nanne was used for AIDS which for them includes HIV. As a result, we found that gonorrhea and other curable STIs and HIV/AIDS are quite common, thus confirming the popular scientific knowledge about the close relationship between untreated STIs and HIV (Ogunsola, 2006; Wingood & DiClemente, 2000; UNFPA, 2001, 2002). Unlike in men, gonorrhea and some other STIs are asymptomatic in women. Hence, their visit to health facilities in search of treatment for an STI was linked to pregnancy. This also indicates the high value attached to children, which acts not only as a push factor for women to seek antenatal care but also to request money and permission to do so during pregnancy. We found from the participants’ narratives that although some female STI sufferers naively seek medical care for pregnancy, others who are aware of having contacted STIs equally assume ignorance of their health conditions
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out of shyness rooted in their socialization and societal expectation. It was mentioned in only one of the male urban groups that women can seek health care for STIs. The general opinion was that most women diagnosed with STIs are pregnant women who visit health facilities for ANC. This resonates with the gender and power theoretical model adopted for this study. It is important to note that contrary to my expectation of getting distinct data from the rural and urban locations, all four sampled communities are predominantly traditional and relatively homogeneous. My expectation, therefore, was not met with regards to this topic. It is instructive that contrary to popular belief, monogamy was mentioned among the factors responsible for the spread of STIs. Most elderly participants believe that rather than polygyny, promiscuity by the monogamous increases the spread of STIs, especially HIV. This calls to question the assertion that polygyny poses great risk of HIV and AIDS and confirms Dixon’s (2004) argument that it is easier to trace sexual partners of those infected with HIV in well-organized community systems than in relatively large and loosely organized populations in cities. Beyond the type of marriage, therefore, a very important factor that shapes the vulnerability of individuals, especially women, to STIs is the nature of gender relations that influence the personal experience of marriage and the level of personal commitment and fidelity of a spouse. Findings here thus substantiate earlier positions that the power imbalance between sexual partners increases women’s vulnerability to HIV and AIDS (Makinwa-Adebusoye, 2006; UNFPA, 2002; Wingood & DiClemente, 2000). We learned that although it is more common among women, HIV infection cuts across gender. This points to how culture prescribes specific behavior patterns for women and men that put them both at risk of STIs in a predominantly heterogeneous society. For instance, not asking a male spouse to use a condom even when a wife mistrusts him is regarded as a sign of a woman’s docility and respect for the man. This implies that a woman who acts contrary to this expectation is likely to be perceived as disrespectful and risks facing the consequence of her action, which could include being subjected to physical assault by the man who supposedly “owns” her and is thus empowered to discipline his erring “property.” Men on the other hand are preoccupied with having to prove their masculinity and sexual virility (Togarasei, 2011) by engaging in sexual exploits with multiple women concurrently as wives, concubines, or friends. Marriage hardly prevents men from philandering (Orisaremi & Alubo, 2012; UNFPA, 2001), whereas a married Tarok woman who engages in illicit sexual relationship risks stigmatization. Thus, gender role stereotypes, which often reflect the double standards in society (Cornwall, 2002; Smith, 2007), have negative implications for the sexual health of both men and women. Even though AIDS was more commonly mentioned for reasons explained above, it can be deduced from the results that STIs are relatively
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widespread across the communities and that there is no discrimination in the treatment available to men and women for STIs. Rather, the discrimination is in access to available treatment. Most of the infected persons do not seek treatment in formal health facilities but from traditional healers, patent medicine stores, and other sellers. This is partly responsible for the under-reporting of STIs in Nigeria and in most developing countries as earlier documented (Dixon, 2004; Ogunsola, 2006). On the whole, men are more courageous to discuss their sexual health problems and seek care from service providers including male laboratory personnel. Apart from men’s experience of gendered socialization, the fact that most of these key traditional and modern service providers are men is also to their advantage. Also, from the service providers’ accounts, we learned that most of the women who access health facilities for STI treatment are either pregnant or are sufferers of PIDs. A corollary of an untreated STI, PID can cause protracted pelvic pain and infertility with all the attendant medical and social implications that may include divorce, multiple sexual partnerships, gender-based violence against women, and so on (Smith, 2007; Togarasei, 2011; Orisaremi & Alubo, 2012). What we found on denial equally confirms Aniekwu’s (2002) position that despite the positive change in the attitude of the general public to the reality of HIV and AIDS sufferers, there is still denial at the various levels of society. This denial underscores the moral issues involved in its transmission and explains why the elderly perceive it as a foreign disease among the young and why men associate it with female promiscuity. Nonetheless, many elderly men marry young girls in addition to their older wives, thereby exposing all parties including the product of such relationships to the risk of STIs. One of the interesting findings of this study was that some men would ask to be given medication to take to their female sex partners. This is apparently linked to the unquestionable obedience that is expected of wives, which makes it easier for the men to make their female partners receive treatment from them. Conversely, women are not expected to discuss sexuality with their male spouse, let alone offer them treatment for STIs. Because informing the man about her infection may ignite all kinds of problems related to distrust, it is often safer for her to assume ignorance while delivering the service provider’s request to have a chat with her male partner. Health providers, irrespective of their gender, generally find this task less difficult to do. More men have the financial resources to pay for their treatment, unlike many women who may have to depend on their male spouse to access treatment. Results of this study, thus, highlight the necessity of education and economic empowerment for women through some income-generating schemes, microfinance, and other self-help projects. Education and economic empowerment of women are critical weapons against the spread of HIV and other STIs in heterogeneous societies.
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CONCLUSION An examination of how unequal gender relations influence the sexual health seeking behavior of the Tarok reveals generally poor access to formal sexual health care. Even though most sufferers of STIs do not access formal health care facilities, men find it easier to access sexual health services from traditional medical practitioners, charlatans, or professionals. Their female spouses are reluctant to seek treatment for STIs for various reasons ranging from the asymptomatic nature of some STIs in women to socioeconomic and cultural reasons that place them at a disadvantaged position vis-`a-vis men. Not only are women less likely to seek treatment for STIs, they are equally more likely to develop STI-related complications like HIV (Wingood & DiClemente, 2000). Besides, STIs including HIV are more efficiently transmitted from man to woman in a heterosexual relationship. Consequently, there cannot be a sustained positive change in HIV prevalence in Nigeria until the challenges of gender inequality in the larger society are addressed.
REFERENCES Aniekwu, N. (2002). Gender and human rights dimensions of HIV/AIDS in Nigeria. African Journal of Reproductive Health, 6, 30–37. Connell, R. W. (1987). Gender and power. Stanford, CA: Stanford University Press. Cornwall, A. (2002). Spending power: Love, money, and the reconfiguration of gender relations in Ada-odo, southwestern Nigeria. American Ethnologist, 29, 963–980. Dixon, P. (2004). AIDS and you (rev. ed.). Secunderabad, India: Operation Mobilization and ACET international Alliance. Ezumah, N. N. (2003). Gender issues in the prevention and control of STIs and HIV/AIDS: Lessons from Awka and Agulu, Anambra State, Nigeria. African Journal of Reproductive Health, 7, 89–99. Federal Ministry of Health. (2008). National HIV/AIDS and reproductive health survey, 2007. Abuja, Nigeria: Author. Federal Republic of Nigeria. (2007). 2006 national census. Retrieved from http://www.nigerianstat.gov.ng/nbsapps/Connections/Pop2006.pdf Makinwa-Adebusoye, P. (2006). Hidden: A profile of married adolescents in Northern Nigeria. Lagos, Nigeria: Action Health Incorporated. Matshalaga, N. (1999). Gender issues in STIs/HIV/AIDS prevention and control: The case of four private sector organizations in Zimbabwe. African Journal of Reproductive Health, 3, 81–96. National Agency for the Control of AIDS (NACA). (2013). Federal Republic of Nigeria, global AIDS response: Country progress report, Nigeria GARPR 2012. Abuja, Nigeria: Author. National Population Commission (NPC) & ICF Macro. (2009). Nigeria demographic and health survey, 2008. Fairfax, VA: Author.
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Njoroge, N., & Wanjiru, P. (2010). The gender perspective. In J. W. Rosenow (Ed.), Multiple and concurrent sexual partnerships: A consultation with senior religious leaders from east and southern Africa (pp. 38–47). Kampala, Uganda: Pan African Christian AIDS Network (PACANet). Ogunsola, F. T. (2006). The role of sexually transmitted infections in HIV transmission. In O. Adeyi, P. J. Kanki, O. Odutolu, & J. Idoko (Eds.), AIDS in Nigeria (pp. 93–130). Cambridge, MA: Harvard Centre for Population and Development Studies. Orisaremi, T. C. (2010). Wives’ strategies for influencing family decision-making in Nigeria: A study of Etuno community, Edo State. African Journal of Modern Society, 1, 109–120. Orisaremi, T. C., & Alubo O. (2012). Gender and the reproductive health of Tarok women in central Nigeria. African Journal of Reproductive Health, 16, 83–96. Persson, A., & Richards, W. (2008). Vulnerability, gender and “proxy negativity”: HIV-negative women in serodiscordant relationships in Australia. Social Science & Medicine, 67, 799–807. Shagaya, J. N. (2005). Taroh history. Smith, D. J. (2007). Modern marriage, men’s extramarital sex, and HIV risk in southeastern Nigeria. American Journal of Public Health, 97, 997–1005. Togarasei, L. (2011). Healing culture, healing AIDS: A review of some cultural and religious practices in contexts of HIV and AIDS. In J. W. Rosenow (Ed.), Ethno cultural factors and HIV and AIDS: A coordinated church response to HIV and AIDS in Africa (pp. 47–62). Kampala, Uganda: Pan African Christian AIDS Network (PACANet). United Nations Joint Programme on HIV/AIDS (UNAIDS). (2010). HIV/AIDS 2009 estimates for Nigeria. Retrieved from http://www.unaids.org/en/ Regionscountries/Countries/Nigeria United Nations Population Fund (UNFPA). (2001). Preventing HIV infection: Protecting reproductive health. New York, NY: Author. United Nations Population Fund (UNFPA). (2002). Gender and HIV/AIDS in SubSaharan Africa: The leadership challenge. New York, NY: Author. Wingood, G. M., & DiClemente, R. J. (2000). Application of the theory of gender power to examine HIV-related exposures, risk factors, and effective intervention for women. Health Education and Behavior, 27, 539–565. Yarnap, G. R. (1985). The missionary factor in Tarok land 1907–1960: A sociopolitical and historical analysis. (Unpublished B.A. Research Project). Department of History, University of Jos, Jos, Nigeria.
ISSN: 0739-9332 (Print) 1096-4665 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcw20
Gender, Sexual Health Seeking Behavior, and HIV/AIDS Among Tarok Women in North-Central Nigeria Titilayo Cordelia Orisaremi To cite this article: Titilayo Cordelia Orisaremi (2014): Gender, Sexual Health Seeking Behavior, and HIV/AIDS Among Tarok Women in North-Central Nigeria, Health Care for Women International, DOI: 10.1080/07399332.2014.971953 To link to this article: http://dx.doi.org/10.1080/07399332.2014.971953
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Health Care for Women International, 00:1–18, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2014.971953
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Gender, Sexual Health Seeking Behavior, and HIV/AIDS Among Tarok Women in North-Central Nigeria TITILAYO CORDELIA ORISAREMI Department of Sociology, Bingham University, Nasarawa State, Nigeria
In this study, which was part of a larger project I undertook in Northcentral Nigeria, I explored the differences in the sexual health seeking behavior of Tarok women and men and how these differences affect the spread of HIV. With the help of three research assistants, I conducted 16 in-depth interviews and 24 focus group discussions in four Tarok communities in North-central Nigeria. I found certain negative effects of gender inequality on women’s sexual health seeking behavior in particular, a situation that has adverse implications for HIV acquisition and transmission. I therefore concluded that addressing the challenges of gender inequality is imperative for a sustained fight against HIV and AIDS in Nigeria.
BACKGROUND Nigeria, the most populous country in Africa, reportedly bears the second highest burden of the human immune deficiency virus (HIV) in the world after South Africa because of its large population size (National Population Commission [NPC] & ICF Macro, 2009). The United Nations Joint Programme on HIV/AIDS (UNAIDS,]2010) estimated that 2.9 million people live with HIV in Nigeria and that women account for 56% of all adults aged 15 years and above who lived with the virus in 2009 in Nigeria. Each year, around 57 000 babies are reportedly born with HIV, most of whom became infected from their mothers, and the estimate of children living with HIV in Nigeria alone reportedly increased from 220,000 in 2007 to 360,000 in 2009 (UNAIDS, 2010). Not only are sexually transmitted infections (STIs) closely related to Received 1 November 2013; accepted 25 September 2014. Address correspondence to Titilayo Cordelia Orisaremi, Department of Sociology, Bingham University, PMB 005, New Karu, Nasarawa State, Nigeria. E-mail: [email protected] 1
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HIV, they are quite common in developing countries and constitute critical issues in public health (Ogunsola, 2006). Nigeria, a country in the West African subcontinent that lies between 0 4 1’ and 1309’ north latitude and between 202’ and 1403’ east longitude, is bordered in the east by the Republic of Cameroun; Republic of Chad in the northeast; north and west by the Republics of Niger and Benin, respectively; and on the south by the Gulf of Guinea. With a total land area of about 923,768 square kilometers, Nigeria’s 2006 population figure was put at 140,003,542 (Federal Republic of Nigeria, 2007) and 167,000,000 in 2011. Approximately two-third of these people live in rural areas. Nigeria is occupied by sundry ethnic groups with distinct traditions, customs, and languages. The Hausa, Fulani, Igbo, and Yoruba are the largest and politically dominant ethnic groups. The country is organized into 36 states and a Federal Capital Territory that make up the Federal Republic of Nigeria. These are subdivided into 774 Local Government Areas. The 36 states are further grouped into six geopolitical zones, namely, North-east, North-west, North-central, South-east, South-west, and South-south. The Tarok ethnic group is found in the Plateau State located in the North Central geopolitical zone that is characterized by a massive concentration of small ethnic groups of autonomous political systems. Since 1991 HIV prevalence in Nigeria has been primarily tracked through the sentinel surveillance of pregnant women (15–49 years) antenatal clinic (ANC) attendees (NPC & ICF Macro, 2009). There is a wide variation of prevalence of HIV epidemic in Nigeria across the six geopolitical zones. The North-central zone had the highest HIV prevalence among ANC attendees with 7.5% compared with 2.1% in the North-western zone (Federal Ministry of Health, 2010). HIV in Nigeria is generally higher among women than men. For instance, an analysis of the 2007 National HIV/AIDS Reproductive Health Survey (National Agency for the Control of AIDS [NACA], 2013) by sex and gender showed 1.9% prevalence for young men aged 20–24, while young women of same age recorded 4.5%. Also, the prevalence reported for young women aged 20–24 was 4.6% compared with 3% among mostly unmarried young women of 15–19 years (NACA, 2013). Besides, the same report shows that the Plateau State has one of the highest HIV prevalence rates in the North-central zone (7.7%). The major determinants of sexual health in Nigeria are sociocultural, economic, and psychological factors among others. STIs, which include bacterial, viral, fungal, and all contagious infections transmitted mainly through “sexual contact with mucous membranes and/or skin surfaces” (Ogunsola, 2006), are quite common in various communities in Nigeria, and an active untreated STI facilitates the sexual transmission and acquisition of HIV. Hence, some previous studies reveal a relationship between untreated STIs and HIV in Nigeria as in other parts of the world burdened with the HIV and AIDS epidemic (Dixon, 2004; Ogunsola, 2006).
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Sociocultural factors are critical in the prevention and treatment of STIs and, by extension, in HIV prevention and management. In addition to influencing the spread of STIs, they induce the manner in which men and women access available modern medical services. Nigeria, which is in the main, heterosexual, and the subsisting patriarchal social structure that is pervasive in societies across Nigeria and indeed Africa, translates gender differences to discrimination and inequality to the detriment of women. Female subordination does not necessarily mean that every man is better off than every woman. Nevertheless, it remains true that more men have greater access to scarce resources and decision making than women. Gender inequality is significant because it inhibits women from being able to determine the nature of their sexual relationships, partnership, and behavior. This negatively affects the sexual health and general well-being of women in particular and limits their ability to make informed choices in relation to practices that directly affect their sexual well-being, including the right to seek health care.
RELEVANT LITERATURE AND THEORETICAL PERSPECTIVE Ezumah (2003) explored the perceptions, practices, and norms underlying sexuality gender relations that constrain STI and HIV prevention and control among the Igbo, and the following factors were found to encourage men and women in engaging in sexual networking: (a) persistence of group norms that attribute passivity to women and control in sexual matters to men; (b) marriage that further disempowers women in sexual matters; (c) fear of repercussion which prevents women from negotiating safe sex practices with their male partners; and (d) persistence of harmful cultural practices that predispose women in particular to STIs and HIV. Dixon (2004) asserted that chronic untreated sexually transmitted diseases (STDs) “are far more common in poorer nations where there are fewer health facilities” and “One of the reasons HIV is spreading so fast in Mumbai in India is that around half of all adults in that vast city are carrying an active untreated STD” (p. 51). The presence of health facilities, however, does not predictably translate to equal access by men and women. Unequal gender relations and other sociocultural factors render untreated STIs a challenge especially for women. Hence, Aniekwu (2002) maintained that sociocultural, legal, and economic factors contribute to women’s susceptibility to HIV and AIDS in Nigeria. Also, Makinwa-Adebusoye (2006) studied the sexual and reproductive health of married adolescents in Northern Nigeria and demonstrated that although sexual activity among female adolescents mainly occurs within the context of marriage, young brides are exposed to STIs because they are married to men who are much older and with whom they have very little capacity to discuss life-threatening infections like HIV/AIDS or to seek health care without their husbands’ consent.
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An investigation into how gender issues influence the outcome of an HIV/AIDS intervention program in Zimbabwe revealed that gender power relations and gender roles in families hinder free flow of communication between female and male spouses and increase the vulnerability of married women unlike their unmarried counterparts (Matshalaga, 1999). Also, the social practice of double standards was identified as an important factor in the transmission of HIV in southeastern Nigeria (Smith, 2007). From a Christian perspective, a study (Togarasei, 2011) reviewed certain African cultural and religious beliefs and practices and argued that they have the potential both for increasing and reducing the spread of HIV and AIDS. Interestingly, virtually all the factors identified were gender related. Furthermore, a consultative study with Christian religious leaders in east and southern Africa on multiple concurrent partnerships reveal how women are blamed for men’s extramarital affairs and how their physiology and a male centered culture makes them suffer far-reaching implications of untreated STIs more than their male spouses (Njoroge & Wanjiru, 2010). Some of the implications mentioned in the study were reproductive tract infections, HIV, cervical cancer, infertility, and sterility. Besides, in a medical study on the role of STIs in HIV transmission in Nigeria, Ogunsola (2006) cited data from other sources that support the existence of a close relationship between STIs and HIV demonstrating that the mere presence of an untreated STI increases the risk of acquiring and transmitting HIV 10 times, while proper management of STIs has the potential to reduce the incidence of HIV infection by 40% in the general population. These studies point to the role of gender inequality in the spread of STIs and HIV within regular relationships, as well as women’s poor access to decision making in STI/HIV prevention. Persson and Richards (2008), however, cautioned against a mere generalized description of gender and power in the vulnerability of women to HIV. They explored the interactions between gendered meanings that surround different serostatuses of heterosexual couples. Specifically, they analyzed the gendered interchange between HIV-negative women and their HIV-positive male partners and the complex ways through which the former negotiate their sexual lives with their HIV-positive male partners in Australia and how gendered meanings attached to women’s negative status help the HIV-positive men to regain their masculinity through what the authors described as “proxy negativity.” Nonetheless, my examination of sexual health seeking behavior and STIs here includes certain anatomical properties of the woman. I shall therefore situate this study within a revised version of Robert Connell’s (1987) theory of gender and power. The theory of gender and power which was developed by Connell (1987) identified three major social structures that characterize the relationship between men and women: (a) the sexual division of labor; (b) the sexual division of power; and (c) the structure of cathexis. These structures operate at both the societal and institutional levels. The presence of imbalance of
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control within relationships, and other discriminatory and institutional practices that are maintained by social mechanisms that hinder women’s control of resources and produce gender-based inequities in expectations of women’s role in society, adversely affect women’s health. Wingood and DiClemente (2000) elaborated upon the theory and developed a public health model out of it. They specifically used it to examine not only the exposures and social and behavioral risk factors but also the biological properties that predispose women to HIV. They identified three domains of interest: public health, social behavioral sciences, and medicine, and they explained that each of these domains corresponds to a level of causation that defines the properties that can both increase women’s risk of disease and prescribe particular strategies for decreasing women’s health risk. For instance, for effective intervention at the public health level, it is important to aim at modifying existing social norms, influencing cultural norms, and reducing barriers to health care. At the social/behavioral level, focus should be on modifying intrapersonal and interpersonal factors through individual and group counselling aimed at altering beliefs, attitudes, and so on. At the biomedical level, the target should be at altering the behavior of individuals by addressing their undesirable health conditions through changing their biochemistry. I judged this model adequate for the current study primarily for the following reasons: (a) it recognizes the interplay between existing social mechanisms present in social institutions (including family relationships and medicine) and how they act to expose women to several socioeconomic, behavioral, personal and medical risk factors and diseases; (b) it provides a holistic approach to explaining how unequal gender power influences women’s health, especially sexual health; and (c) it explains the link between perceptions of symptoms and health-seeking behavior. From the foregoing, concerns of sexual health include medical and nonmedical conditions, and the latter provides the much-needed enabling environment for it to thrive. Preventive campaigns are insufficient especially in this era where HIV/AIDs and other STIs have increasingly become development issues. The main objective of this article, therefore, is to go beyond the provision of modern sexual health information and services to explore in-depth and document how gender inequality influences sexual health seeking behavior and the implication of this for the sexual acquisition and transmission of HIV among the Tarok. The Tarok ethnic group is found in the Plateau State located in the north-central geopolitical zone of Nigeria. The two principal religions in Tarok land are traditional religion and Christianity. The latter, however, has assumed dominance in Tarok land in recent times. In the early twentieth century, Christian missionaries of the Sudan United Mission (SUM) arrived in Tarok land (Shagaya, 2005; Yarnap, 1985). These missionaries brought formal education and medical services, as well as new values such as
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one-man one-wife. The Tarok people embraced Western education and many, upon completion, sought paid employment in the urban centers. Contact with Western lifestyle, the introduction of a cash economy, and so on led to an increase in monogamy especially among Christians. In spite of the spread and the rapid growth of Christianity in Tarok land, traditional beliefs and custom abound. Prevailing gender-based social and cultural beliefs and practices that are traits of resilient patriarchal structures influence virtually every aspect of the sexual life of the Tarok. These include the definition of sexuality, the nature of sexual relations and partnerships for men and women, the nature and types of marriage (Orisaremi & Alubo, 2012), and gender differences in access to decision in relation to the use of available modern health care services. These gender-based differences often translate to gender inequality and provide the context within which sexual norms and behavior exist. As with most ethnic groups in Nigeria, marriage was considered a very important social duty, and procreation was the primary reason for this. Male children were preferred. Men were encouraged in traditional times to marry many women and have large families to cultivate large farmlands. This was generally perceived as a status symbol. Fertility was attributed to women, while virility was characteristic of men. Consequently, stigma and other social burdens associated with childlessness were largely borne by women. Where a married man was found to be sterile, it was possible to secretly arrange for his female spouse to bear children through his agnatic brother, so as to ensure continuity of his patrilineage. On the contrary, a childless wife hardly had a place in her matrimonial home. The most common option available to her was to encourage her husband to marry other women capable of bearing children to obviate her shame. Thus, as in many other societies in Nigeria, infertility was a major reason for women’s acceptance of cowives (Orisaremi, 2010). The Tarok practice strict lineage exogamy. Until the introduction of Christianity, the residential pattern was predominantly patrilocal, whereby the man and each uterine family had a separate hut. This residential pattern implied that authority, control, and inheritance were vested in the male head of the family, and it also facilitated the practice of polygyny. Sociocultural beliefs and norms rooted in patriarchal structures, as well as unequal gender relations, play a critical role in the sexual health seeking behavior of married couples in Tarok communities.
METHODS This study was part of a larger research titled Gender Relations and the Reproductive Health of Tarok Women, which was aimed at exploring how
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unequal gender relations influence the reproductive processes and the reproductive health of Tarok women in Nigeria. Fieldwork was conducted in four Tarok communities in the Langtang North Local Government Area of the Plateau State, namely, Langtang, Gazum, Reak, and Pilgani in April–May 2008. Gazum and Reak are rural, while Langtang and Pilgani are urban areas. These localities were selected because traditional sociocultural practices that are significant to this study are usually better preserved at the grassroots, while changes that have taken place over time are better depicted in urban areas. I used in-depth interviews (IDIs) and focus group discussions (FGDs) for data gathering. Participants in IDIs in each community comprised a community leader, a religious and a woman leader, as well as a senior modern health service provider from a public or private health facility who had worked in the community for not less than 3 years and was conversant with the sociocultural practices of the Tarok. The focus groups consisted of female and male community members with a good knowledge of the mores, social norms, workings, and practices of the community in relation to the issues of interest. These were purposively selected to reflect the social differences in the communities in terms of age, gender, religion, educational and marital status, etc., and separate focus groups were constituted to reflect these differences and to ensure the homogeneity of each group. A structured questionnaire with 10 simple questions on their sociodemographic background such as age, gender, religion, marital status, highest level of education attained, income earning activities, and so on, was administered to each of the potential participants prior to the constitution of the focus groups. This was to enable an initial contact and to ensure homogeneity in the constitution of the groups for enhanced interaction. The purpose of the research was explained to the selected participants, and informed consent was verbally obtained from each of them prior to the IDI and FGD sessions. Four IDIs and six FGDs (three each for men and women) were conducted in each community. All eligible respondents for the IDI sessions were interviewed. Each IDI lasted about an hour and FGD an hour and a quarter on average. All research issues were canvassed in each IDI and FGD session. This article simply presents the subsection on STIs and health-seeking behavior. The minimum age for the IDI participants was 38 years and 15 years for FGD participants. On the whole, 41.5% of all participants were 50 years and above, while those below 50 years made up 58.5%. Participants of the FGD between 15 and 24 years accounted for 18.6%, and the 25–34 age category constituted 28.5%. Tables 1 and 2 present the background characteristics and distribution of the 16 IDIs and the 24 FGDs. I used loosely structured IDI and FGD guides as the major instruments for data gathering. Flexibility characterized the ordering of the questions so as to circumvent an atmosphere of formality, given the sensitivity of the
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Characteristic District Langtang Pilgani Gazum Bwarat Sex Female Male Age 38–49 years 50–59 years 60–69 years 70 and above Religion Christian Traditionalist Marital status Single Married Widowed Education No formal education Primary Secondary Tertiary Position in community Women leader Traditional leader Religious leader Senior modern health service provider Income earning activity Full-time farming Petty trading and farming Paid employment and farming Paid employment, farming and trading Pensioner in part-time farming Community service and part-time farming Community service only
Number (total N = 16) 04 04 04 04 06 10 05 02 06 03 14 02 01 14 01 03 04 01 08 04 04 04 04 03 02 03 01 02 04 01
Source: Fieldwork, April–May, 2008.
issues associated with sexuality. All IDIs and FGDs were conducted in Tarok, Hausa, and English languages and auto-recorded. All three research assistants and I were involved in the data gathering, transcription, and translation into the English language. This was done within 24 hours of each IDI and FGD, with supplementary information from the notes taken so as to allow for a quick clarification of any confusion or uncertainties and minimize memory loss. To ensure an authentic descriptive account of results, I sorted findings question by question, issue by issue, group by group, and community by community making notes of major opinions, feelings, and attitudes of the groups and participants in order
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Gender, Sexual Health Seeking Behavior, and HIV/AIDS TABLE 2 Social Background Characteristics of Focus Groups Number (total N = 24)
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Characteristic District Langtang Pilgani Gazum Bwarat Sex Female Male Age 15–24 years 25–34 years 35–49 years 50–59 years 60–69 years 70+ Religion Christian Traditionalist Marital status Single Married Widowed Education No formal education Primary certified Attempted secondary Attempted tertiary Income earning activity Full-time farming Petty trading only Petty trading and farming Paid employment and farming Paid employment, farming and trading Pensioner in full-time farming None (schooling)
06 06 06 06 13 11 05 05 05 04 03 02 22 02 02 19 03 05 09 06 04 04 02 04 06 03 03 02
Source: Fieldwork, April–May, 2008.
to have an overview of findings. Thereafter, I organized and presented the relevant aspects of the content of the IDIs and FGDs in line with the major themes that emerged in relation to gender, sexual health seeking behavior and HIV/AIDS in this article using verbatim quotations to illustrate responses where necessary.
RESULTS Gender Differences in Sexual Health Seeking Behavior The majority of the male and female participants held that men find it easier to seek health care for STIs because (a) their anatomy makes it easier to recognize the symptoms; (b) they are more “courageous” to
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talk about it; and (c) more men have the financial resources to pay for treatment:
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The men find it easier to go for treatment because they are often not as shy as the women. . . . Men are courageous; they do not hide their feelings. But the woman feels shy and may be afraid of how to go and tell them in the clinic, while the man will courageously go and face them. (FGD, 35–49, female, no formal education, rural district) Once a man feels the infection in his body, he starts seeking treatment even before the woman starts feeling any pains. . . . That is how God made the man. . . . He knows it is very important to seek treatment for the disease, so he goes and pays for it. (FGD, 25–34, male, secondary, urban district)
This contrasts with the situation of many women who may have to ask for money from their male spouses in order to seek treatment, and who are often too shy to talk about sex organs because of the nature of their socialization: Women cannot go on their own for medication because they do not like talking about it until it becomes really bad. . . . They also find it hard to ask their husbands for money to go to the clinic for such a disease. . . . At most they try traditional herbal treatment like ikun Tarok (a traditional herbal mix). (FGD, 50–59, female, no formal education, urban district) Very few women go easily. Others would go but would not mention what the true problem is. They may therefore be given the wrong treatment. (FGD, 60–69, female, primary education, rural district)
An urban-based middle-aged educated female participant, however, held an alternative view that either of the sexes who needs medical care for STIs goes freely to any health facility without any hindrance: It does not matter. . . . Man or woman can go to the hospital in search of sexual health care.
Interactions with all four senior service providers reveal that STIs are quite common and that while most sufferers tend to seek care from traditional medical practitioners, more men than women access treatment whether from charlatans or qualified service providers. Additionally, participants mentioned that although very few women seek health care for STIs, women who attend ANCs and present any form of complaints of urinary tract infection or lower abdominal pain are usually advised to run STI tests in health centers, and they often test positive. According to the service providers, many women are often not aware that they have STIs, while others who suspect
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they are infected are very shy to discuss it. Many female clients who present with STIs, therefore, tend to complain about lower abdominal pains, which they usually relate to pregnancy:
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The women often come with lower abdominal pains thinking it is pregnancy . . . without knowing it is STI until we find out. (IDI, 52, male, tertiary education, urban district) The women usually have pelvic inflammatory diseases (PIDs). They may complain of itching and lower abdominal pain, so after [the] test, you treat her accordingly. . . . Some may tell you they have painful menstruation, colored and concentrated urine; some will say they are itching . . . they have rash and things like that. Many a times they associate their complaint of lower abdominal pain with pregnancy, and most of those who come with such complaints are pregnant women. (IDI, 47, female, tertiary education, urban district)
Men generally recognize the symptoms faster, and they tend to seek treatment before the women by first patronizing patent medicine stores and herbalists who are mostly men before seeking care in health facilities if the ailment persists. Asked the kind of traditional treatment given for STIs, the vast majority of the participants, young and old, male and female, specifically mentioned the use of traditional herbal treatment (ikun Tarok) and an herbal mix prepared primarily from the roots or leaves of a particular herb called kwakwali and ja-kanwa (red potash): For gonorrhea, there are certain roots used. For instance, roots of kwakwali plant that they mix with some other things. They boil and give it to the patient. The same treatment is used for men and women traditionally. (FGD, 30–39, male, secondary education, urban district) To treat nping gbang-gbang (“smelly urine,” used to refer to gonorrhea), there is a type of leaf called kwakwali that is squeezed and mixed with ja-kanwa, and it is left for about 30 minutes before it is given to the patient to drink. (FGD, 70+, female, no formal education, rural district)
A minority of the participants were of the opinion that in these modern times, however, some of those infected men or women resort to modern health facilities for the treatment of gonorrhea: Gonorrhea was treated with ikun Tarok (Tarok native herbal medicine), but these days it is taken care of in the hospital. (FGD, 60–69, male, primary education, urban district)
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The service providers mentioned that most of the men who visit health centers for STIs often go directly to the men in the laboratory to demand a test instead of consulting the female nurses:
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When male clients come, most of them go straight to the lab man and complain to him. . . . He quietly runs the test, and, if positive, the lab man would now hand over the result to the right personnel for treatment. (IDI, 47, female, tertiary education, urban district)
The service providers equally mentioned that they normally would ask their clients to come with their sex partners. Asked how willing these partners are in accompanying the former for treatment, they said that while most people would agree to accompany their spouses to the clinic for treatment if invited, it is almost impossible to get unmarried sex partners to present together because of the illicit nature of their sexual relationship or cowives in polygynous marriages except where the husband was the first to be diagnosed. Two of the service providers equally mentioned that in some cases the men would ask to be given drugs for their female partners to avoid bringing them to the health centers where most service providers are women. On the other hand, it was reported that the women would rather look for some diplomatic ways of informing their male spouse of the request of the service providers to have a chat with them or pretend not to know why an invitation is extended to their husbands by the service providers.
Perception of How Common HIV Is in the Community and of its Sources of Transmission It is important to note that HIV does not exist in the local dialect. Instead, it is perceived as a synonym for AIDS, and AIDS is referred to in the Tarok language as nanne or fungshat ku zing (nanne or fungshat ku zing literally means “eight” or “seven-plus-one.” It is derived from the similarity in the sound of the words “AIDS” and “eight”). A majority of all categories of participants mentioned that nanne is common in all the communities especially among youth and women. Very few mentioned that it affects both sexes equally. These opinions are illustrated below: In those days there was gonorrhea, which they called tonzere, but now AIDS is more common especially among the youth and young women. (FGD, 50–59, female, secondary education, rural district) There is a lot of cases of AIDS here among both men and women. (IDI, 52, male, tertiary education, urban district)
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There were indications that the very few participants who expressed the view that AIDS is more common among men, based their opinion on the results of medical tests organized by voluntary organizations in which most of the community members tested were men:
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AIDS is more nowadays. . . . There are persons with HIV/AIDS in this community. Some missionaries came to screen people recently, and they found many persons, especially young men, with AIDS. (IDI, 66, male, primary education, urban district)
Asked if the tests were made available to both men and women, the following was the response from one of the participants: Kai! Who will allow his wife to go for such a test in public? It was mainly for men. (IDI, 66, male, primary education, urban district)
An elderly woman explained how widespread AIDS is: These days sexually transmitted infections are found everywhere kaman karshi (like feces ). . . . Our children are dying regularly. . . . No group is exempted. . . . Even the funeral we are just returning from was that of an AIDS sufferer. . . . We simply find our children drying up until they get to the size of this stick (showing her walking stick) and then they die. (FGD, 70+, female, no formal education, rural district)
The dominant opinions can be summarized thus: (a) HIV/AIDS is more recent than tonzere or gonorrhea; (b) gonorrhea and AIDS are more common in all communities; and (c) HIV/AIDS is more common among young persons and women. Some of the sources of transmission of gonorrhea and AIDS identified by participants follow: indiscriminate sexual activities especially among young persons; sexual indiscipline (particularly among men) and monogamy; as well as indecent dressing among young girls. While the young men blamed the girls, young women equally felt that young men were culpable. Also the practice of widow inheritance (ntem akup) that is still relatively common even among Christian men was equally mentioned by a service provider in an urban district as a possible source of transmission of HIV: One thing that worries me most is this issue of wife inheritance. . . . A husband dies, you don’t know what killed him, you go and inherit the wife, and before you know it, the whole family is infected with HIV. There are many cases of HIV, AIDS, and other STIs here and it cuts across all ages and all sexes whether man or woman.
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Remarkably, the majority of elderly male participants expressed the view that tonzere/gonorrhea and HIV/AIDS are not indigenous but foreign infections brought in by young people who travelled out of Tarok land to places where they indulged in licentious behavior. This is illustrated in the following statements:
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Tonzere was a disease brought by those who travelled to Lafia and places like that. (FGD, 70+, male, no formal education, rural district) Gonorrhea was brought back by the men who went for First and Second World War. They brought it from outside the country and it is spread through sex. (IDI, 78, male, primary education, rural district) We did not know anything called AIDS in those days. It is only now that when people travel they come back with it. Even those of us here know that it is not indigenous but imported into Tarok land. (FGD, 60–69, male, primary education, urban district)
This belief largely expressed by elderly men, who curiously are the custodians of culture including moral values, is clearly connected to the moral issues involved in the predominant mode of transmission of HIV infection, which the majority of the participants identified as sex. The belief indicates denial.
DISCUSSION Discussion of STIs among all categories of participants was generally limited to gonorrhea and AIDS. This is clearly related to the fact that among the Tarok, gonorrhea is often used in the everyday parlance of nonmedical persons in general reference to STIs. Accordingly, participants tended to refer to all types of curable STIs as gonorrhea, while nanne was used for AIDS which for them includes HIV. As a result, we found that gonorrhea and other curable STIs and HIV/AIDS are quite common, thus confirming the popular scientific knowledge about the close relationship between untreated STIs and HIV (Ogunsola, 2006; Wingood & DiClemente, 2000; UNFPA, 2001, 2002). Unlike in men, gonorrhea and some other STIs are asymptomatic in women. Hence, their visit to health facilities in search of treatment for an STI was linked to pregnancy. This also indicates the high value attached to children, which acts not only as a push factor for women to seek antenatal care but also to request money and permission to do so during pregnancy. We found from the participants’ narratives that although some female STI sufferers naively seek medical care for pregnancy, others who are aware of having contacted STIs equally assume ignorance of their health conditions
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out of shyness rooted in their socialization and societal expectation. It was mentioned in only one of the male urban groups that women can seek health care for STIs. The general opinion was that most women diagnosed with STIs are pregnant women who visit health facilities for ANC. This resonates with the gender and power theoretical model adopted for this study. It is important to note that contrary to my expectation of getting distinct data from the rural and urban locations, all four sampled communities are predominantly traditional and relatively homogeneous. My expectation, therefore, was not met with regards to this topic. It is instructive that contrary to popular belief, monogamy was mentioned among the factors responsible for the spread of STIs. Most elderly participants believe that rather than polygyny, promiscuity by the monogamous increases the spread of STIs, especially HIV. This calls to question the assertion that polygyny poses great risk of HIV and AIDS and confirms Dixon’s (2004) argument that it is easier to trace sexual partners of those infected with HIV in well-organized community systems than in relatively large and loosely organized populations in cities. Beyond the type of marriage, therefore, a very important factor that shapes the vulnerability of individuals, especially women, to STIs is the nature of gender relations that influence the personal experience of marriage and the level of personal commitment and fidelity of a spouse. Findings here thus substantiate earlier positions that the power imbalance between sexual partners increases women’s vulnerability to HIV and AIDS (Makinwa-Adebusoye, 2006; UNFPA, 2002; Wingood & DiClemente, 2000). We learned that although it is more common among women, HIV infection cuts across gender. This points to how culture prescribes specific behavior patterns for women and men that put them both at risk of STIs in a predominantly heterogeneous society. For instance, not asking a male spouse to use a condom even when a wife mistrusts him is regarded as a sign of a woman’s docility and respect for the man. This implies that a woman who acts contrary to this expectation is likely to be perceived as disrespectful and risks facing the consequence of her action, which could include being subjected to physical assault by the man who supposedly “owns” her and is thus empowered to discipline his erring “property.” Men on the other hand are preoccupied with having to prove their masculinity and sexual virility (Togarasei, 2011) by engaging in sexual exploits with multiple women concurrently as wives, concubines, or friends. Marriage hardly prevents men from philandering (Orisaremi & Alubo, 2012; UNFPA, 2001), whereas a married Tarok woman who engages in illicit sexual relationship risks stigmatization. Thus, gender role stereotypes, which often reflect the double standards in society (Cornwall, 2002; Smith, 2007), have negative implications for the sexual health of both men and women. Even though AIDS was more commonly mentioned for reasons explained above, it can be deduced from the results that STIs are relatively
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widespread across the communities and that there is no discrimination in the treatment available to men and women for STIs. Rather, the discrimination is in access to available treatment. Most of the infected persons do not seek treatment in formal health facilities but from traditional healers, patent medicine stores, and other sellers. This is partly responsible for the under-reporting of STIs in Nigeria and in most developing countries as earlier documented (Dixon, 2004; Ogunsola, 2006). On the whole, men are more courageous to discuss their sexual health problems and seek care from service providers including male laboratory personnel. Apart from men’s experience of gendered socialization, the fact that most of these key traditional and modern service providers are men is also to their advantage. Also, from the service providers’ accounts, we learned that most of the women who access health facilities for STI treatment are either pregnant or are sufferers of PIDs. A corollary of an untreated STI, PID can cause protracted pelvic pain and infertility with all the attendant medical and social implications that may include divorce, multiple sexual partnerships, gender-based violence against women, and so on (Smith, 2007; Togarasei, 2011; Orisaremi & Alubo, 2012). What we found on denial equally confirms Aniekwu’s (2002) position that despite the positive change in the attitude of the general public to the reality of HIV and AIDS sufferers, there is still denial at the various levels of society. This denial underscores the moral issues involved in its transmission and explains why the elderly perceive it as a foreign disease among the young and why men associate it with female promiscuity. Nonetheless, many elderly men marry young girls in addition to their older wives, thereby exposing all parties including the product of such relationships to the risk of STIs. One of the interesting findings of this study was that some men would ask to be given medication to take to their female sex partners. This is apparently linked to the unquestionable obedience that is expected of wives, which makes it easier for the men to make their female partners receive treatment from them. Conversely, women are not expected to discuss sexuality with their male spouse, let alone offer them treatment for STIs. Because informing the man about her infection may ignite all kinds of problems related to distrust, it is often safer for her to assume ignorance while delivering the service provider’s request to have a chat with her male partner. Health providers, irrespective of their gender, generally find this task less difficult to do. More men have the financial resources to pay for their treatment, unlike many women who may have to depend on their male spouse to access treatment. Results of this study, thus, highlight the necessity of education and economic empowerment for women through some income-generating schemes, microfinance, and other self-help projects. Education and economic empowerment of women are critical weapons against the spread of HIV and other STIs in heterogeneous societies.
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CONCLUSION An examination of how unequal gender relations influence the sexual health seeking behavior of the Tarok reveals generally poor access to formal sexual health care. Even though most sufferers of STIs do not access formal health care facilities, men find it easier to access sexual health services from traditional medical practitioners, charlatans, or professionals. Their female spouses are reluctant to seek treatment for STIs for various reasons ranging from the asymptomatic nature of some STIs in women to socioeconomic and cultural reasons that place them at a disadvantaged position vis-`a-vis men. Not only are women less likely to seek treatment for STIs, they are equally more likely to develop STI-related complications like HIV (Wingood & DiClemente, 2000). Besides, STIs including HIV are more efficiently transmitted from man to woman in a heterosexual relationship. Consequently, there cannot be a sustained positive change in HIV prevalence in Nigeria until the challenges of gender inequality in the larger society are addressed.
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